Encountering Culture: Psychotherapy and Counseling Practice in India

Evolving cultures in a changing society, encounters with culture in the therapy space, integration and grounding.

Western or scientific psychology was introduced in India in 1905 at Calcutta University (Prasadrao & Sudhir, 2001). In 1915 a full-fledged department of psychology was instituted and Girindrashekhar Bose, a practicing Indian physician, became the first recipient of a doctorate in psychology in 1921. In 1922, Bose founded the Indian Psychoanalytic Society. After India became an independent democracy in 1947, premier mental health institutions were set up for providing preventive, curative and rehabilitative health care. National Institute for Mental Health and Neurosciences (NIMHANS) in Bangalore and Central Institute of Psychiatry in Ranchi were the earliest centers offering higher education in psychiatry, psychiatric social work and clinical psychology. Psychotherapy became an essential component of these qualifications (Neki, 1995). Fifty years down the line, the earlier trend of medicalized treatment has given way to counseling services (George & Thomas, 2013). There is greater mobility of Indians within the country and abroad, and people in larger cities and towns are asking for therapeutic counseling, to deal with emotional issues. Modernization and changing lifestyles seem to increase the need for therapy and also make it an acceptable form of help.

A Changing Society

Globalization has transformed the cultural land-scape of India. Growth of industries and migration from rural to urban centers has created the promise of economic well-ness as well as disappointments. Education and employment of women, especially in urban areas, call for reorientation of roles, responsibilities and power between genders, a welcomed shift for many women. Availability of mass media and modern communications has exposed people to ideas from western societies that led to a shift towards pursuit of person-al goals and profit making enterprise (Carson & Choudhray, 2000). Among the concerns of current times are marital strain, parent-child conflicts, domestic violence, delinquency, substance abuse, low achievement in poorer families, and stress for high academic achievement in the higher income groups. Family bonds are affected because the joint family system that promotes collectivist values such as cohesion and interdependence is no longer the norm, especially in cities. Child rearing practices foster earlier independence for young adults. Indians who come to therapy may have worldviews that are very traditional, quite modern or a mix of both. There are clients in difficult marriages yet avoiding the stigma of divorce. There are progressive young adults living together without being married and talk openly about cohabiting. In addition, there are joint families where couples struggle to save their marital relationships in the face of intergenerational conflicts. Interdependence also continues by elders being involved in arranging marriages, helping in child rearing, and old parents living with adult children and being cared by them. ‘Compartmentalization’, the ability to function with newer skill sets or values in one area of life and retain the older values in another area, serves well as an adaptation to modernisation (Singer, 2007).

Evolving Culture of Psychotherapy

Systemic theories from the West are fairly applicable but certain peculiarities of Indian families call for slightly modified treatment strategies. Nath and Craig (1999) remind us that marriages in India have always been more than an alliance between the spouses unlike the West where it is a bond between two ‘individuated’ persons. The conflicts that clients present can challenge the counselor to examine their own value system. The effort to preserve the resilience of families and mental health of individuals against stresses of modern times has resulted in a significant development in family therapy services. Family therapy in modern India offers ways to strike a balance between the “tyranny of the collective and the alienation of individualism” (Oommen, 2000; as cited in Carsen & Chowdhury, 2000, p. 398). Mental health professionals have been able to engage families as an effective sys-tem of care when treating individuals with mental illness such as Schizophrenia (Chadda & Deb, 2013).

Training of counselors has received more attention only in the last two decades although there were many established departments of academic psychology in the country. The need for counseling and guidance for a growing population in schools and colleges has led to starting a number of postgraduate courses in counseling psychology (Arulmani, 2007). Institutions such as Parivarthan in the south Indian city Bangalore, offer training in counseling for mature middle-aged individuals from non-psychology background and en-sure rigor through appropriate supervision (www.parivarthan.org). There are other practitioners oriented towards Transactional Analysis and maintain allegiance to the international TA association. A committed group of professionals has meticulously introduced EMDR training to psychologists, counselors and social workers (www.emdrindia.org). There is renewed interest in psychoanalysis in various metropolitan locations such as Delhi and Ahmedabad. One can also meet Jungian analysts in India who advocate the healing potential of dreams and mythological motifs. Service providers and users are capitalizing on the technologies available for long distance counseling. The variety of professionals available in urban India matches the plurality of the culture itself.

Cultural psychology is an emerging field and many of those who come to study bring their individual concerns reflecting social realities (Sapru, 1998). Psychology helps the students to articulate these concerns and find ways to cope, which in turn contributes to wider social transformation. Counselors trained in Western models effectively assimilate the cultural context in helping individuals and couples to find a balance between their relational and individual needs (Bala, 2007). Reviewing literature on psychotherapy practice in India, Manickam (2010) observes that while the authors’ theoretical orientation to therapy varied over the years, a consistent concern for most of them was to assimilate indigenous concepts to meet client needs. Smoczyinski (2012) explores how counselors trained in Western approaches to counseling adjust their practice at an urban counseling center in Bangalore according to the local context. She views this process of adaptation in terms of glocalisation, drawn from the field of social constructionism. According to this concept, practice from one part of the world is transferred as an abstract idea to another part where it is actively received, modulated and put into further practice in this other context. Another critical concern facing professional therapists across the country is to collaborate towards consolidation of ethical guidelines and regulation of counseling and psychotherapy practice in India.

Encounters with Culture in the Therapy Space

India is a multilingual society. Training at universities and training institutes is conducted mostly in English due to availability of standard texts and training resources. Neki (1995) urged his contemporaries to attend to psycholinguists because how people speak can say much about the mind structure and cultural stance towards life and living. A few professionals have undertaken translation of psychological concepts into a vernacular form despite some inherent challenges. Many English terms such as ‘shame’ cannot be substituted with Indian words conveying the same connotations just as certain cultural expressions cannot be expressed accurately in English. Nonetheless, a majority of therapists are likely to be conversant with at least one Indian language and do not hesitate to tune into a client’s preferred mode of communication. Therapy in context, then, truly becomes the co-creation of all participants. Some lighter moments are experienced when the client can sense the therapist’s genuine effort and correct their vocabulary, making for warm bonding between both. 

The role of emotions in human experiencing is an important issue to contend with when applying constructs originating from a different culture. While physiological processes involved in regulation of emotions may be the same for all people, it is increasingly acknowledged that cultural regulation plays a significant mediating role (De Leersynder, Boiger, & Mesquita, 2013). Indian art and literature offer an enormous vocabulary and discussion on affect and emotion. Yet like other Asians, traditional Indians believe that emotions such as anger are damaging to relationships and are to be avoided in everyday life. It is hard for them to participate in exploration of feelings. Indian therapists of yesteryears who noticed this in their clients called it a ‘cultural de-fence’ (Varma, 1986). In such cases, mythological stories or fables allow for a profound sublimation of difficult emotions in the presence of a compassionate observer. Stories with relevant themes or characters can be spontaneous expressions from clients (Ramnathan, 2013). At other times, the therapist takes a lead to evoke the necessary image and aspired coping (Bhatt, 2010). 

The egalitarian stance advocated by Western approaches is a much debated issue and many therapists have written that it is unhelpful and ineffective in the Indian context (Neki, 1979). In contemporary times, such difficulties are seen less frequently yet not completely absent. Clients asking for advice and anticipating direction is not uncommon. In a study by Smoczyski (2012), several counselors describe how they manage such a challenge by carefully exploring the client’s worldview to elicit the advice or solution being sought and offer it back in a constructive form. Arulmani (2009) has proposed that cultural preparedness is a necessary condition for counseling to be effective in non-western communities. He describes it as the ability to provide culturally relevant counselling that matches the client’s expectation. A therapist may find herself being greeted with a handshake by a man and with a Namaste (i.e., joining both hands) from his wife (Bhatt, 2010). Some clients, including English-speaking individuals, can be at a loss when asked to address the therapist by first name because it is a practice that is common only between equals. Indians amongst other Asians who grow up in a Western environment often seem to function independently in some areas of life and yet in other spheres demonstrate deep-seated hierarchical attitudes as inculcated in their families (Kakar, 2003). In a society that has a hierarchical structure, tradition assigns roles, tasks and position, based on age and gender. Men, older members and individuals with valued qualities or qualifications are ascribed a higher place. The person lower down in the order, expresses deference and the other in the higher role reciprocally offers caring and protection. Chin (1993) observes a ‘hierarchical transference’ when working with Asian clients in America. She suggests that for some clients it is facilitative to transcend the hierarchy and for some it is beneficial to reciprocate as expected. 

Neki, a leading psychiatrist in the 1970s, observed that Indian clients often tended to look up to the therapist as a Guru (Neki, 1979). According to him, Indian society traditionally promotes social dependency and dependability. Within such a cultural context it was reasonable, that clients considered a therapist as a teacher who could show them a way out of dilemmas. However, this attitude seems to be waning. Today’s therapist is more likely to be seen as a consultant or a collaborator, going by the comment, “If the middle mental space between the body and the soul needs repair, the doctor or the guru is no use, it needs its own specialist to heal it” (Vishwanathan, 2005, as cited in Wadhwa, 2005). Based on conversations with professionals across several cities of India, Wadhwa (2005) reports that over the last decade urban Indians openly acknowledge their vulnerabilities and seek therapy proactively compared to earlier days when many patients were referred by their doctor. Some clinicians still maintain that talk therapy is less effective when patients present with physical complaints, which are more socio-culturally acceptable ways to receive attention. These individuals speak less and still expect the doctor to understand their mental state (Wasan, Neufeld, & Jayaram, 2008). When hard pressed for time, many psychiatrists are likely to use medications to get maximum impact in shorter time. There are, however, psychiatrists who keenly practice psychotherapy or refer their patients to counselors (Bhatt, 2010). Furthermore, there are therapists who also advocate other forms of healing that their clients can benefit from. The alternate methods are seen to address the person’s inner conflicts through different but equally plausible interpretations mediated by metaphors and archetypes relevant to their cultural identity. Moodley (1999) describes how an Indian client who lived in the West could be helped through talk therapy up to a point and was further healed successfully by an indigenous ‘doctor’. In retrospect, he believes, it was wise to hold back an interpretation of ‘splitting’ because the client found an integration of his ‘divided selves’ with the other practitioner. 

Integration and Grounding

The acceptability of Western psychotherapy and counseling professionals has not diminished the popularity of older healing practices (Arulmani, 2007). The Eastern approach cannot conceive of a separation between psychology and spirituality since both are concerned with the study and understanding of human nature (Varghese, 1998). According to Ayurveda, a traditional system of life science in India, wellness is a delicate balance between the mind, body, and spirit. Yoga offers time tested means to regulate the body, the breath and the mind leading to stillness- “observing transforms the observer- a radical resolution for inner discord and almost a God experience”, describes Rao (2008, p. 299). Yoga and Vippasna, another Eastern discipline, commonly referred to as Mindfulness, are being incorporated into psychotherapy in the West as they overlap in their goals of helping a person to develop unconditional friendliness to oneself. Folk wisdom directs people to undertake regulated activities through social, vocational, creative and religious commitments, as meaningful engagement in life can help to develop equanimity. Communal practices such as musical chanting or attending discourses based on various philosophical texts remain popular for seeking solace or insight. Other sources of support are Meditation, Pranic healing, and Astrology. The cultural tradition of India is spiritual and this tradition includes influences of religions, religiosity, practice of various rituals and festivals (Arulmani, 2009; Thomas, 2010). It is not unusual for a Hindu to consult a Fakir (i.e., a Muslim sage) or visit particular churches associated with healing images of a Christian god or saint. Psychotherapy and counseling practice in India is positioned to be enriched by all streams of knowledge. Western psychotherapy offers a way to address the panic in the journey towards the unknown and strengthen an ego, which can only then be surrendered in the spiritual quest, as articulated by Varma (2004).

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The article was originally published in International Psychology Bulletin (Volume 19, No. 1) Winter 2015

Gayitri Bhatt

Trainer, Supervisor & Therapist at Parivarthan Counseling Training and Research Centre.